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Anomalous Retro-Psoas Iliac Artery Is an Extremely Rare Congenital Iliolumbar Vascular ( Anomaly

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Anomalous Retro-Psoas Iliac Artery Is an Extremely Rare Congenital Iliolumbar Vascular ( Anomaly J Korean Soc Radiol 2020;81(6):1511-1516 Case Report https://doi.org/10.3348/jksr.2020.0002 pISSN 1738-2637 / eISSN 2288-2928 Received January 4, 2020 Revised February 15, 2020 Accepted April 9, 2020 Anomalous Retro-Psoas Iliac *Corresponding author Youngjun Kim, MD Department of Radiology, Artery: A Case Report Presbyterian Medical Center, 365 Seowon-ro, Wansan-gu, 허리근뒤 이상 온엉덩동맥: 증례 보고 Jeonju 54987, Korea. Tel 82-63-230-8006 Beum Jin Kim, MD , Youngjun Kim, MD* Fax 82-63-230-8387 E-mail [email protected] Department of Radiology, Presbyterian Medical Center, Jeonju, Korea This is an Open Access article distributed under the terms of the Creative Commons Attribu- tion Non-Commercial License The anomalous retro-psoas iliac artery is an extremely rare congenital iliolumbar vascular (https://creativecommons.org/ anomaly. A 51-year-old woman presented to our emergency department with worsening right licenses/by-nc/4.0) which permits unrestricted non-commercial lower extremity pain and weakness for 3 months. CT angiography of the right lower extremity use, distribution, and reproduc- showed no evidence of stenosis in the lower extremity arteries and the incidental finding of an tion in any medium, provided the original work is properly cited. anomalous right retro-psoas iliac artery. Herein, we report a rare case of anomalous retro-pso- as iliac artery. Surgeons and clinicians need to be aware of this rare congenital anomaly to avoid severe complications during pelvic or orthopedic surgery. ORCID iDs Beum Jin Kim Index terms ‌Iliac Artery; Congenital Abnormalities; Cardiovascular Abnormalities https:// orcid.org/0000-0002-9111-5617 Youngjun Kim https:// orcid.org/0000-0003-4638-9229 INTRODUCTION The anomalous retro-psoas iliac artery is an extremely rare congenital iliolumbar vascular anomaly (1-5). Our literature review revealed only six reported cases of the anomalous retro-psoas iliac artery. Usually, they are incidentally detected on imaging or at autopsy, as the patients are asymptomatic. We incidentally detected the presence of the retro-psoas iliac artery located between the right psoas muscle and the adjacent vertebral body. If rare congenital anomalies of the iliac arteries are not recognized, they may complicate aortoiliac or vertebral surgery (1-5). Therefore, herein, we report a case of the anomalous right retro-psoas iliac artery incidentally found on CT angiography. CASE REPORT A 51-year-old Asian woman presented to the emergency department with worsening right lower extremity pain and weakness for 3 months. On physical examination, good femoral and peripheral pulses were palpated in both lower extremities. Neurological examination showed normal motor and sensory functions. Routine laboratory tests were within normal limits. The patient had a past medical history of hypertension, back pain, and total abdominal hysterectomy. Brain CT and MRI showed no evidence Copyrights © 2020 The Korean Society of Radiology 1511 Retropsoas Iliac Artery of acute infarction, hemorrhage, or mass-like lesions that could have caused the patient’s symptoms. Lower extremity CT angiography showed no evidence of stenosis in the lower ex- tremity arteries. During this examination, the tortuous right iliac artery was detected inci- dentally. The abdominal aorta was located more laterally toward the left side rather than at the center before the bifurcation (Fig. 1A). The anomalous right iliac artery originated at the L3–L4 disc level with a more latero-posterior course at an acute angle than that on the con- tralateral side (Fig. 1A, B; arrow showing the abdominal aorta and anomalous right iliac ar- tery). This anomalous artery was situated between the right psoas muscle and the vertebral bodies behind the inferior vena cava and right iliac vein (Fig. 1C-E). The anomalous right iliac artery did not bifurcate into the internal and external iliac arteries as on the left side and gave off multiple collateral branches serving the role of both the internal and external iliac arteries (Fig. 1F). At the inguinal ligament level, the anomalous right iliac artery was found at its normal position, continuing as the femoral artery. The contralateral left iliac artery showed no unusual anatomical orientation. Fig. 1. A 51-year-old woman with the right anomalous retro-psoas iliac artery. A. The anteroposterior view of the volume-rendered reconstruction image of CT angiography shows the anomalous right retro-psoas iliac artery bifurcating at the L3–L4 disc level with a more latero-posterior course at an acute angle than that on the contralateral side (arrowheads). The abdominal aorta (arrow) is located more laterally toward the left side rather than at the center before the bifurcation. Note the absence of bifurcation into the external and internal iliac arteries distally. B. The lateral view of the volume-rendered reconstruction image of CT angiography shows a more latero- posterior course of the right anomalous retro-psoas iliac artery (arrowheads) than that of the normal left common iliac artery. A B 1512 jksronline.org J Korean Soc Radiol 2020;81(6):1511-1516 Fig. 1. A 51-year-old woman with the right anomalous retro-psoas iliac artery. C-E. Axial CT angiography shows the course of the right anomalous retro-psoas iliac artery (arrows) situated between the right psoas muscle and the vertebral bodies behind the inferior vena cava and right iliac vein. F. Axial CT angiography shows the right anomalous retro-psoas iliac artery (arrow) giving off a collateral branch (arrowhead) as the left inter- nal iliac artery. C D E F DISCUSSION The anatomy of the common iliac artery is rather fixed. It originates from the aortic bifur- cation at the level of the L4 vertebra and runs infero-laterally for approximately 4 cm before running along the medial border of the psoas muscles to its bifurcation at the pelvic brim in front of the sacroiliac joints (3). Each artery bifurcates into the external and internal iliac ar- teries. The external iliac artery continues as the common femoral artery as it crosses under the inguinal ligament to supply the lower extremities. The internal iliac artery traverses the upper sacral regions and gives off multiple branches supplying the pelvic viscera and muscu- loskeletal structures (4, 6). Vascular anomalies of the iliac arteries are rare, and their definite embryological mecha- nism remains unknown (1-5). In 1977, Greebe (7) reported six cases of iliac artery anomalies in a series of approximately 8000 patients who underwent angiography of the pelvic artery. https://doi.org/10.3348/jksr.2020.0002 1513 Retropsoas Iliac Artery The most common iliac artery anomaly is the persistent sciatic artery with iliofemoral aplasia, which classically presents as a pulsatile buttock mass and no femoral pulse. In 1983, Honkasa- lo et al. (8) reported a case of the retrocaval right iliac artery in a patient with an aortic aneu- rysm. In that patient, the anomalous iliac artery travelling behind the psoas muscles was con- firmed surgically. In 1991, Vohra and Leiberman (1) reported a case of the anomalous right common iliac artery with stenosis running behind the psoas muscle on CT. In 1998, Sonneveld et al. (2) first coined the term “retro-psoas iliac artery” while searching for an abdominal aor- tic aneurysm to describe the anomalous right common iliac artery running between the ver- tebral body and the psoas muscle. All six case reports of the retro-psoas iliac artery published in the literature were found on the right side and none on the left side (1-5). All of them arose from the aortic bifurcation at a 90° angle at the level of the L3 or L4 vertebral body, being positioned between the psoas mus- cle and the vertebral body. The anomalous retro-psoas iliac artery did not bifurcate into the internal and external iliac arteries in any case except that reported by Honkasalo et al. (8). In the case reported by Vohra and Leiberman (1) the patient complained of right lower extremity pain, and angiogram showed stenosis in the right retro-psoas iliac artery. Pain alleviated with the bypass graft procedure. In the case reported by Delasotta et al. (4), the patient presented with progressively worsening right lower extremity pain, which was managed with anterior lumbar interbody fusion and physical therapy. In all other reported cases, the patients were asymptomatic, and the artery was incidentally found while investigating for aneurysms or other underlying diseases. Lower extremity pain, as in our case, may have occurred because of the more laterally run- ning course of the anomalous retro-psoas iliac artery, compressing the adjacent lumbar nerve roots or lumbar plexus, causing neuralgia (4). Furthermore, the risk of complications, such as fistula, hematoma, or pseudo-aneurysm, may increase in such vascular anomalies, and there- fore, recognizing this vascular anomaly is important (5). In our case, smaller collateral branches from the anomalous right retro-psoas iliac artery extending to the territory of the internal iliac artery was subtly evident. These small branch- es may have developed to compensate for the absence of the internal iliac artery. With devel- opment of the collateral branches, the anomalous retro-psoas iliac artery seemed to serve the role of both the internal and external iliac arteries without division. Embryologically, the umbilical arteries arise when the embryo is less than 1.5-mm long, from the most caudally situated branches of the primitive dorsal aorta (6). The axial artery arises from the umbilical artery, with its proximal part becoming the sciatic artery, middle part becoming the deep peroneal artery, and distal part becoming the embryonic interosse- ous artery. Proximal to the origin of the axial artery, the external iliac artery branches off from the umbilical artery. From the external iliac artery, the inferior epigastric artery and proxi- mal part of the femoral artery arises.
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